An infant has been born with an esophageal atresia and tracheoesophageal fistula. What is the priority preoperative nursing diagnosis?

Risk for aspiration related to regurgitation

Acute pain related to esophageal defect

Ineffective tissue perfusion gastrointestinal related to decreased circulation

Ineffective feeding pattern related to uncoordinated suck and swallow

Answer and Explanation

The Correct Answer is A

a) Risk for aspiration related to regurgitation: With esophageal atresia and tracheoesophageal fistula, the risk of aspiration due to the abnormal connection between the trachea and esophagus is a significant concern. Preventing aspiration is a priority.

b) Acute pain related to esophageal defect: Pain might be present but managing the risk of aspiration is more immediate.

c) Ineffective tissue perfusion gastrointestinal related to decreased circulation: While important, preventing aspiration takes precedence.

d) Ineffective feeding pattern related to uncoordinated suck and swallow: A valid concern but not as critical as the risk of aspiration.

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Correct Answer is ["B","C","D","E","F"]

Explanation

a) Eupnea: Normal breathing rate and pattern, not indicative of distress.

b) Apnea: Cessation of breathing, a sign of significant distress.

c) Tachypnea: Rapid breathing, often seen in respiratory distress.

d) Wheezing: High-pitched, musical sounds during expiration, suggesting airway obstruction.

e) Grunting: Heard during expiration, a sign of the body's attempt to keep air in the lungs, indicating distress.

f) Retractions: Visible sinking of tissues between ribs or at the sternum, indicating increased effort to breathe, a sign of distress.

A. Constant parental supervision is needed to avoid overexertion B. The child needs opportunities to play with others C. The parents can have the child make video calls with friends instead of playdates D. The child needs to understand that peers’ activities are too strenuous

Correct Answer is B

Explanation

a) Constant parental supervision is needed to avoid overexertion: While supervision is important, restricting all activities might limit the child's development.

b) The child needs opportunities to play with others: Encouraging social interaction and play with peers is crucial for the child's social and emotional development.

c) The parents can have the child make video calls with friends instead of playdates: Video calls can supplement but should not entirely replace physical play and interaction.

d) The child needs to understand that peers’ activities are too strenuous: This response might unnecessarily limit the child's participation in normal activities without considering their abilities and limitations.

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An infant has been born with an esophageal atresia and tracheoesophageal fistula. What is the priority preoperative nursing diagnosis?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which breath sounds indicate the infant is experiencing respiratory distress? (Select All That Apply: SATA)

Correct Answer is ["B","C","D","E","F"]

Explanation

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Correct Answer is B

Explanation

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